seven years ago; instead of the incisions through the cheek or lip, or
both of these parts, he merely slits open the lip exactly in the mesial
line, as far as the columna of the nose, and then carries the knife
along one side of the base of the columna into the nostril, next the
tumour. He says: “By opening the nostril in this way as much relaxation
was gained as if the knife had been carried from the root of the ala an
inch up the side of the nose, and as much facility was given for the
future steps of the operation, as if an incision three inches in length
had been made through the lip and side of the nose, while a grand object
was gained in leaving the slightest possible conspicuous appearance
afterwards.”[146] This plan has the further great advantage of avoiding
the very copious hæmorrhage which arises from a deep incision in the
side of the face.
In one of the operations which was performed before this improvement was
introduced, the patient died of hæmorrhage. The case is related by Mr.
Prescott Hewett in the _Medico-Chirurgical Transactions_ for 1851. This
operation was performed in St. George’s Hospital, in May 1848, with the
consent of the surgical staff of the hospital. The patient was a man,
aged twenty-five; the tumour was of nearly six years duration. For some
time previous to the operation, he had suffered occasionally from
hæmorrhage from the affected nostril, to an extent which had reduced him
considerably. The vapour was given to him rather slowly, with the
apparatus I commonly employ, and he became gradually insensible, without
previous excitement or struggling. In about three minutes, the
inhalation was discontinued, the narcotism having reached the third
degree. The patient was passive, but the muscles were not relaxed. The
breathing was not stertorous. Some teeth were now extracted without
causing any sign of pain. A little more chloroform was then given to
him, and when the inhalation was discontinued a second time, he was in
the same state as before the teeth were drawn. The operation was
immediately commenced. The superior maxillary and malar bones of the
left side were removed. During the first part of the operation, whilst
the flaps were made, the patient was perfectly quiet and silent; but
afterwards he began to groan and move his limbs, and he was not again
rendered altogether insensible; for although a few minims of chloroform
were from time to time sprinkled over a sponge, which was, now and then,
held near his face, yet, owing to the hands of the operator and his
assistants being in the way, and the cavity of the mouth and nostril
being laid widely open, he got very little of the vapour, and the only
effect of it was partially to quiet him on one or two occasions. After
the first two or three minutes of the operation, the effect of the
chloroform never exceeded the second degree. The patient executed
voluntary movements of his arms and legs; sometimes it was necessary to
hold his hands, and at one time he appeared conscious, for he folded his
arms as if making an effort not to raise his hands to the seat of pain.
He coughed now and then, and seemed somewhat embarrassed with the blood
in his throat. He was seated in a chair, but as there was no window in
the operating theatre except the skylight, his head was obliged to be
inclined rather backwards. He was leaned forwards once or twice, to
allow him to get rid of the blood, and it appeared that he vomited some
on one of these occasions. Towards the conclusion of the operation, and
at a time when he was very little under the influence of chloroform, he
fainted. He was laid down, and brandy was given to him. No more
chloroform was administered after this time. He partially rallied from
the syncope, but again became faint. The actual cautery was applied, but
oozing of blood continued until the moment of death,—about half an hour
after his removal into another room. During this interval, he was much
exhausted; his pulse was small, and difficult to feel. He was tossing
himself about in a restless manner, but there was no difficulty of
breathing. He seemed quite conscious, doing as he was told, but, of
course, could not speak, from the nature of the operation. I left a few
minutes before the patient’s death. When he ceased to breathe,
laryngotomy was performed, and artificial respiration exercised by the
opening, with no beneficial result. In my opinion, this measure was not
indicated, but of course it could do no harm.
One of the surgeons who was present when the patient died informed me
that blood entered his windpipe from the wound, when he became moribund.
It was found during the operation that the tumour did not involve the
superior maxillary or malar bones, but was situated behind them. In his
address to the class immediately after the operation, Mr. Hewett
estimated the loss of blood at sixteen ounces. It appeared to me to be
much greater; besides that a great deal of blood would certainly be
swallowed.
After death, portions of the tumour were found still remaining attached
to the posterior and upper part of the cavity, and projecting into the
foramen lacerum of the orbit and right nostril, as well as in other
directions. The trachea and bronchi contained some frothy blood.
Numerous small dark spots of congestion were met with in the lung,
resulting from some of the small bronchi being filled with blood.
The late Mr. Liston lost a patient from hæmorrhage during the removal of
a tumour of the upper jaw, before the prevention of pain by inhalation
was discovered; and it is evident that the chloroform did not contribute
either directly or indirectly to the death of Mr. Hewett’s patient. His
symptoms were simply those of exhaustion from loss of blood; he
recovered from the effects of the chloroform some time before he died;
and the small quantity of blood which spotted the lungs, and was
observed to enter as he was dying, would not have led to any immediate
urgent symptoms if it had entered during the operation.
_Tumours of the Lower Jaw._ I have notes of twelve cases in which I have
given chloroform during this operation. Eight of the operations were
performed by Mr. Fergusson, and the others by Mr. Stanley, Mr. Tatum,
Mr. Hancock, and Dr. Pettigrew. In some of the cases the jaw was divided
on each side above its angles, and in most of the others it was
disarticulated on one side, and divided near the symphysis. Three of the
patients died within three days, from the hæmorrhage which occurred at
the time of the operation, but the others all recovered.
The remarks which were made respecting the application of chloroform in
the removal of tumours of the upper jaw are applicable here. After the
operation has been commenced, one should endeavour to keep up the
insensibility by means of a mixture of chloroform and spirit on a hollow
sponge. In tumours, both of the upper and lower jaw, the operating table
is preferable to an easy chair for the patient under chloroform. The
head and shoulders must be raised by the movable flap of the table, or
by some other contrivance if the operation be performed in a private
house. I have, however, seen the operation performed on a sofa, and with
the patient in bed. The blood does not flow into the throat so much in
the removal of tumours of the lower jaw, as in those of the upper one.
_Tumours of the Female Breast._ I have memoranda of 222 cases in which I
have given chloroform during the removal of tumours of the breast, or
tumours which returned after the breast had been removed. I do not
include with these a considerable number of small tumours, situated
upon, and near the gland, but not involving it. By far the greater
number of the tumours of the breast were looked upon as malignant, but I
am not able to state the numbers which were believed to be malignant,
and which were thought not to be so. I may state that there is no
surgeon whom I am in the habit of assisting who does not occasionally
remove malignant, as well as non-malignant, tumours of the breast. By
far the greatest proportion of the above mentioned operations on tumours
of the breast were performed in private practice. In a number of cases
diseased glands were removed from the axilla, in addition to the mammary
gland. It is desirable in the removal of large tumours of the breast
that the surgeon should be well seconded, by assistants who are in the
constant habit of assisting him, in order that the bleeding may be
restrained and arrested as quickly as possible. I have not seen any case
in which the patient did not go through the operation, and live, as far
as I can remember, for two or three days. But a few of the patients have
been very faint from bleeding during the operation, and faintness from
hæmorrhage seldom takes place during the influence of chloroform unless
the loss of blood is very great. The greater portion of the patients who
have been faint during the operation have done well afterwards, but a
few of them have not. In cases where there is a great loss of blood, and
a very large wound remains, the patients are apt to sink and die in from
three to five days. Most patients may recover from a considerable
hæmorrhage, and most patients may be able to bear up during the healing
of a large wound, but the combination of a great hæmorrhage and a great
wound is apt to be fatal; especially to patients who are already reduced
by illness. The largest tumour of the breast I have seen removed, was
one on which Mr. Fergusson operated, in King’s College Hospital, on Feb.
26th, 1853; it weighed eighteen pounds and a half. On the 4th of June,
following, the same patient had a small tumour removed from the same
situation. It probably resulted from a portion of the large one which
had been left behind.
There are a few surgeons who prefer to have the patient seated in an
easy chair whilst removing a tumour of the breast; but it is more
convenient, under the influence of chloroform, that the patient should
lie on a table, or sofa, or in bed. I usually keep the patient
unconscious till the wound is stitched up, and the plaster and bandage
applied.
I have administered chloroform in four cases of tumour of the male
breast. These tumours were all of them malignant, I believe.
_Other Tumours._ I have had to administer chloroform during the removal
of several large and deep-seated tumours of the face, situated just in
front of the ear, over the parotid gland, with which some of them were
thought to be connected. These operations were generally extremely
difficult and tedious, owing to the necessity of avoiding the division
of the branches of the facial nerve which passed over the tumour. When
the branches of the facial nerve are touched with the forceps, or back
of the scalpel, during these operations, the muscles of the face to
which the branches are distributed contract very freely, at a time when
the patient is perfectly insensible. Mr. Stanley, Mr. Fergusson, and Mr.
Tatum, are amongst the surgeons whom I have assisted in the removal of
tumours of this kind.
I have memoranda of 41 tumours situated behind the angle of the jaw, in
the removal of which I have exhibited chloroform. These tumours, which
mostly consisted of diseased lymphatic glands, were often very
deep-seated, passing near to the carotid artery, and it was necessary on
that account to keep the patient quite insensible, to prevent his
flinching during the operation. The greater number of these tumours were
removed by Mr. Fergusson.
Seventy-one of the tumours of the removal of which I have notes, are
stated to have been of the encysted kind. Sixteen of them were situated
on the eyelids, sixteen on the scalp, three or four in the orbit,
several in front, or at the side of the neck, and the rest in different
parts of the body.
I have memoranda of 66 fatty tumours which were removed from different
parts of the body. Some of them were of great size; one weighed fifteen
pounds. One which Mr. Fergusson removed in 1855 from the arm of a lady,
the patient of Messrs. Maurice and Harris of Reading, was situated
beneath the biceps muscle, and weighed two pounds six ounces and a half.
The diagnosis of it was very difficult. The fatty tumours were easily
removed, except in a few instances, in which the fat was infiltrated in
the surrounding tissues.
I have notes of the removal of 87 other tumours of various kinds, as
fibrous, scirrhous, epithelial, melanotic, fungoid, etc.
On February 11th, 1854, Mr. Fergusson removed a large fibrous tumour,
situated over the right scapula of a stout gentleman about forty. It
weighed about three pounds. The tumour was very adherent to all the
surrounding tissues, and the removal of it occupied five or ten minutes,
and was attended with considerable hæmorrhage. At the time when the
tumour was completely detached, the patient became pale, and the pulse
could no longer be felt in either wrist or in the temporal arteries. He
did not faint, however, for the breathing continued to be well and
regularly performed. He partially recovered his feeling once or twice,
whilst the vessels were being tied, and more chloroform was given to
him. At the end of the operation he was quite conscious, and did not
complain of being faint, although no pulse could be felt. The pulse had
not returned when I left him half an hour after the operation, and I was
informed that it did not return for about three hours. Four hours after
the operation, when I called to see him, he had a frequent and very
distinct pulse. He had some hot brandy and water just after the
operation, and about ten minutes afterwards he insisted on going to the
water-closet in the next room, and could not be persuaded to lie still.
The moment he was raised on his feet, however, he fainted, but was
immediately laid down again, when he as quickly recovered his
consciousness, and was content to lie still. This was the only faintness
he had. It is my opinion that the effect of the chloroform kept up the
breathing and prevented syncope, whilst the smaller arteries of the
exterior of the body contracted so as to confine the remaining blood
very much to the vital organs. The patient seemed in some danger for two
or three days, but was walking out quite well in less than a fortnight.
In April 1856, Mr. Paget removed a fibro-cellular tumour, weighing
probably ten or twelve pounds, from a lady a few weeks out of her
confinement. The tumour was situated over the sacrum and nates. Sir
Benjamin Brodie was present at the operation. The patient recovered
favourably.
_Nævi._ I have memoranda of 116 operations on vascular tumours, the
greater part of them in infants. The operations have generally been
performed by subcutaneous ligature, and have been extremely successful.
The greater number of them have been performed by Mr. Fergusson and Mr.
Bowman, in private practice and in King’s College Hospital. Some of the
nævi on the faces of infants, which were operated on by Mr. Fergusson,
were very large, and required a succession of operations.
_Ligature of Arteries._ I have administered chloroform in three cases of
ligature of the carotid artery, by Mr. Bowman, Mr. Lane, and Mr. Haynes
Walton. Mr. Walton’s patient was an infant six months old. The right
common carotid artery was tied, on account of a tumour which pushed
forward the eye to a great extent. On the child being brought under the
influence of chloroform, the prominence of the eye diminished very much,
as I was informed that it had done when chloroform was given for some
reason on a previous occasion. On the ligature being placed under the
artery, the chloroform was discontinued, and its effects allowed to
subside before the ligature was tied. As the effects of the chloroform
went off, the eye became as prominent as before; and the tightening of
the ligature had no effect on this prominence whilst I remained,
although it instantly stopped the pulsation of the temporal artery. I
was informed that this child was cured by the operation.
I have also administered chloroform in three cases of ligature of the
external iliac artery, for aneurism of the femoral. Two of the
operations were performed by Mr. Fergusson, and the other by Mr. Henry
Smith. One of Mr. Fergusson’s patients was a very stout gentleman; the
external iliac artery was diseased at the usual situation of the
ligature, and it had to be tied near to the common iliac. This patient
died. Mr. Henry Smith’s patient recovered, as I believe did the other of
Mr. Fergusson’s. It is necessary that the patient should be kept very
insensible during the operation of tying the carotid or external iliac
artery, to prevent the possibility of his flinching.
I have exhibited chloroform six times for the ligature of the
superficial femoral artery, on account of aneurism in the popliteal
space. Two of these operations were performed by Mr. Bowman on the same
man with an interval of three weeks. He had an aneurism in the popliteal
space of both limbs. There was a case of false aneurism of the radial
artery, on which Mr. Fergusson operated by tying the artery above and
below, and turning out the clot; and also a case in which Mr. Hancock
tied the vessels for a false aneurism, situated between the metacarpal
bones of the thumb and forefinger. There were two cases also in which
the radial artery was tied for a recent wound; one by Mr. Henry Charles
Johnson, the other by Mr. Henry Lee.
_Tumours of Bone._ I have administered chloroform in a number of cases
of the removal of enchondroma, and other tumours of bone. In June 1849 I
assisted the late Mr. Aston Key whilst he removed a bony tumour from a
youth about sixteen, situated at the inner and anterior part of the
femur, just above the knee; and I have seen two or three other tumours
of the same kind, exactly in the same situation. I have no notes of the
other cases; but one was a patient of Mr. Quain, and another, I think,
of Mr. Fergusson. After an incision is made, the tumour can be clipped
clean off at once with a pair of strong, curved bone nippers. Unless the
bone nippers are curved, the operation is troublesome and difficult.
_Hare-Lip._ I have notes of 147 operations for hare-lip, for which I
have given chloroform. A few of these operations were performed by Mr.
Arnott, Mr. Cæsar Hawkins, Mr. Bowman, Mr. Henry Charles Johnson, and
others, but nearly nine-tenths of the whole number were performed by Mr.
Fergusson, either in his private practice or in King’s College Hospital.
A great number of Mr. Fergusson’s operations were in children from three
to six weeks old; and some were younger than this, one being only eight
days. There used to be an objection against operating for hare-lip on
very young infants, as it was said that they often died of convulsions,
which I believe to be true. The convulsions were supposed to be caused
by the shock of the operation on the nervous system, which I believe to
be entirely untrue. I believe they were caused by hæmorrhage; and I
would not recommend the surgeon to perform his first operations for
hare-lip on very young and feeble infants. The great success of this
operation of late years, in the first weeks of life, depends on the
dexterity of the surgeon who performs the operation so quickly that
scarcely any blood is lost. When Mr. Fergusson performs this operation,
the infant is held by a nurse, who is seated opposite to him, whilst its
head is placed in his own lap between his thighs. An assistant
compresses the labial artery on the right side, by grasping the lip
between his finger and thumb, just at the angle of the mouth; a
sharp-pointed scalpel is pushed through the lip on the right side, just
below the nose, and carried downwards so as to cut away the edge of the
fissure; then the same performance is done on the left side of the
fissure, while Mr. Fergusson compresses the labial artery on that side
with the finger and thumb of his left hand. In about twenty seconds from
the beginning of the operation, the hare-lip pins are introduced, and
the cut edges of the lip being pressed together, the bleeding is at once
entirely stopped. I have no doubt that many lives are saved by early
operation, especially amongst the poor, as a child with a bad hare-lip
cannot take the breast till it is operated on, and there is a very great
mortality amongst infants brought up by hand.
The blood which escapes when the infant is laid on its back flows back
into the throat, and it usually passes on each side of the epiglottis,
and runs into the stomach without any act of deglutition. In a few cases
of strong children, in whom the bleeding is rather free, the breathing
gets embarrassed, and Mr. Fergusson turns the face of the child
downwards for a moment to let the blood run out of its mouth. When the
quantity of blood flowing into the throat is greater than can run down
into the stomach, in the way I have mentioned above, the glottis closes
and the breathing stops, which gives the indication for turning the face
downwards. I have seen a few operations in the hospital for hare-lip,
without chloroform, whilst the children were on their backs. In these
cases they cried violently from the pain, set the blood in the mouth
into violent commotion, and then drawing a deep inspiration, drew a
little of the blood into the larynx, which caused a violent cough; so
that there was usually much more appearance of choking than in the cases
where chloroform was given. Moreover, in these latter cases, it is
usually towards the end of the operation that the children sometimes
become embarrassed with the blood; not because the quantity of blood is
greater, but because the sensibility is returning. I have seen one case
which shows that the effects of chloroform, when deep or long continued,
will diminish the sensibility of the glottis. After an infant was made
insensible some years ago for an operation for hare-lip, it was found
that an instrument for dividing the projecting intermaxillary bone was
wanting, and I kept the child insensible for several minutes, by
administering chloroform occasionally, until the instrument was found;
the bleeding was rather free, and some of it entered the windpipe and
caused a tracheal râle. The child coughed it up on awaking, and no ill
consequences followed; but the occurrence confirms the opinion
previously expressed, that the insensibility should not be both deep and
long continued at a time when copious hæmorrhage is flowing into the
throat. The effects of chloroform pass off very quickly in infants, and
it is not often that they last till the operation of hare-lip is
finished, short as that operation is. In private practice, indeed, when
the parents of the infant are close by, I usually have an opportunity to
apply a little chloroform, mixed with spirit, on a sponge, in the course
of the operation, when it is required to prevent crying; but in the
hospital, the children sometimes cry a little before the operation is
concluded.
_Cancer of the Lip._ I have memoranda of nineteen cases of cancer of the
lower lip, and three or four of the upper lip, in which I have
administered chloroform. As there is never an easy chair in the
operating theatre of an hospital, and it is difficult to keep the
patient in a common chair when he is under the influence of chloroform,
it is better to place the hospital patient on the operating table, with
his head and shoulders raised during this operation; but in private
practice the patient may either be placed on a sofa, or in a large easy
chair with a high back. The effect of the chloroform often lasts to the
end of the operation, if it be completed within two or three minutes;
but I always go provided with a hollow sponge, and a mixture of
chloroform and spirit to apply during the operation, if required.